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LIBRA RY O F CONGRESS. 

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UNITED STATES OF AMEEIOA. 



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PHILADELPHIA 



Social Science Association. 



IsoMioaoI Persons ill HosjMs to tie lasie. 



* READ BEFORE THE ABO\^E ASSOCIATION, OCTOBER 2 3D, 1 879. 



— BY — 

Dr. ISAAC RAY. 



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Reprint from PENN MONTHL Y for January, 1S8 ?. 



PUBLISHED BY THE 

PHILADELPHIA SOCIAL SCIENCE ASSOCIATION, 

720 LOCUST STREET, PHILADELPHIA. 



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THE FOLLOWING IS A LIST OF THE PAPERS READ BEFORE THE 
ASSOCIATION. 



1871. Compulsory Education. By Lorin Blodget. Out of print. 
Arbitration as a Remedy for Strikes. By Eckley B. Coxe. 

The Revised Statutes of Pennsylvania. By R. C. McMurtrie. Out of print. 
Local Taxation. By Thomas Cochran. 
Injant Mortality. By Dr. J. S. Parry. 

1872. Statute Law and Cotnmon Law, and the Proposed Revision in Pennsylvania. 

By E. Spencer Miller. Out of print. 
Apprenticeship. By James S. Whitney. 
The Proposed Amendments to the Constitution of Pennsylvania. By Francis 

Jordan. 
Vaccination. By Dr. J. S. Parry. 
The Census. By Lorin Blodget. 

1873. The Tax System of Pennsylvania. By Cyrus Elder. 

The IVork of the Constitutional Convention. By A. Sydney Biddle. 

What shall Philadelphia do with its Paupers? By Dr. Isaac Ray. 

Proportional Representation. By S. Dana Horton. 

Statistics Relating to the Births, Deaths, Marriages, etc., in Philadelphia. By 
John Stockton-Hough, M.D. 

On the Value of Original Scientific Research. By Dr. Ruschenberger. 

O71 the Relative Influence of City and Country Life, on Morality, Health, Fe- 
cundity, Longevity and Mortality. By John Stockton-Hough, M.D. 

1874. The Public School System of Philadelphia. By James S. Whitney. 
The Utility of Government Geological Surveys. By Prof. J. P. Lesley. 
The Law of Partnership. By J. G. Rosengarten. 

Methods of Valuation of Real Estate for Taxation. By Thomas Cochran. 
The Merits of Creviation. By Persifor Frazer, Jr. 
Outlines of Penology. By Joseph R, Chandler. 

1875. Brain Disease, and Modern Living. By Dr. Isaac Ray. Out of print. 
Hygiene of the Eye, Considered with Reference to the Children in our Schools. 

By Dr. F. D. Castle. 
The Relative Morals of City and Country. By Wm. S. Pierce. 
Silk Culture and Home Industry. By Dr. Samuel Chamberlaine. 
Mind Reading, etc. By Persifor Frazer, Jr. 

Legal Status of Married H o?nen in Pennsylvania. By N. D. Miller. 
The Revised Statutes of the United States. By Lorin Blodget. 

1876. Training of Nurses for the Sick. By John H. Packard, M.D. 

The Advantages of the Co-operative Feature of Building Associations. By 

Edmund Wrigley. 
The Operations of our Building Associations. By Joseph I. Doran. 
Wisdo?n in Charity. By Rev. Charles G. Ames. 

1877. Free Coinage and a Self- Adjusting Ratio. By Thomas Balch. 
Building Systems for Great Cities. By Lorin Blodget. 
Metric System. By Persifor Frazer, Jr. 

1878. Cause and Cure of Hard Ti?nes. By R. J. Wright. 
House-Drainage aftd Sewerage By George E. Waring, Jr. 

A Ilea for a State Board of Health. By Benjamin Lee, M. D. 
The Germ Theory of Disease, and its Present Bearing upon Public and Per- 
sonal Hygiene. By Joseph G. Richardson, M.D. 

1879. Delusive Methods of Municipal Financiering. By Wm. F. Ford. 
Technical Education. By A. C. Rembaugh, M.D. 

The English Methods of Legislation Cofnpared with the American. By 

Simon Sterne. 
Ihoughts on the Labor Question. By Rev. D. O. Kellogg. 
On the Isolation of Persons in Hospitals for the Insane. By Dr. Isaac Ray. 



ON THE ISOLATION OF PERSONS IN HOSPITALS FOR 

THE INSANE. 



WHEN a man loses his reason, it becomes necessary that the 
reason of others, in a greater or less degree, shall supply 
its place. To that extent, the movements of the person thus 
afflicted are subject to the control of others, and his property is 
taken from his management and disposal. Humanity demands 
this ; the peace and safety of society demand it, and the ultimate 
good of all parties is promoted by it. Thus, of necessity, one of 
the hardest penalties of the criminal law is visited upon men who 
have not only committed no crime, but are themselves the victims 
of as sad a calamity as any in the long catalogue of human ills. 
The manner in which this consequence is determined, however, 
differs very much in the two cases. In the one, it follows a judicial 
investigation conducted according to the strictest forms of legal 
procedure, with all the safeguards and indulgences which, in the 
progress of humanity, have come to be regarded as unquestionable 
rights ; while in the other, in most instances, it is determined by 
the arbitrary will of individuals proceeding under none of the or- 
dinary formalities of law, and guided by none of its principles. 

The inquiries which this first view of the subject suggests are 
deeply interesting, because the idea now prevails that the legisla- 
ture should prescribe under what circumstances this interference 
with the inalienable rights of men, on the ground of insanity, is to 
be allowed ; to whom this privilege of interference is to be en- 
trusted ; by what safeguards against abuse this trust is to be pro- 
tected ; by what solemnities this deprivation of liberty and pro- 
perty is to be accompanied and recorded. Precisely what legisla- 
tion the exigencies of the case require, is one of the much vexed 
problems in social science. To solve it satisfactorily to all is simply 
impossible, because much of its difficulty proceeds from the circum- 
stance that well-established facts and incontrovertible reasoning 
are deprived of their legitimate force by the influence of passion, 
prejudice and temperament. 



In the first place, let us understand the requirements made 

necessary by the nature of the disease, the social and domestic 

relations of the patient, and those attentions that are instinctively 

prompted by the ties of blood and friendship. In the next place, 

•we are to see how these requirements are provided for by law. 

Beginning, then, with first principles, let it be observed that in 
the more sudden and violent forms of insanity, the patient is neces- 
sarily placed under unceasing surveillance, his wishes are disre- 
garded, medicine and food may be forced upon him, and his limbs 
subjected to restraint. And yet all this — because necessary to the 
patient's welfare — is justified by the common sense and common 
feelings of mankind. No outrage is supposed to be committed, no 
right is trampled on, no apprehension of abuse is excited. On the 
contrary, the friends are regarded as under a moral obligation to 
interfere, as far as the circumstances require, and substitute their 
will for the will of the patient. So, too, nobody would question 
the right of a man to confine his wife in his own house, were she bent 
on self-destruction, or disposed to injure her children. The same 
position would be rightfully held by the wife towards the husband, 
by the parent towards the child, by the child towards the parent. 
No one would question the propriety of such a measure. To ab- 
stain from it, in fact, would be justly regarded as a most reprehen- 
sible neglect of duty. Now, it is not very obvious how, in the sub- 
sequent stages of the disease, this obligation can be lessened, or any 
different one created. [Does there necessarily occur a period when 
society is bound to assume, in any degree, a charge for which the 
friends are no longer fitted ? Neither does it appear how this right 
can become a wrong, by making the place of confinement some 
other than one's own home. If, in the progress of knowledge and 
philanthropy, institutions have become established expressly for 
the care of the insane, in which they are supposed to be more 
successfully treated than they can be at home, it would seem as if 
the natural right in question would be all the more heartily recog- 
nized by making choice of them for this purpose. This right has 
been distinctly recognized and established in this commonwealth 
by an act of General Assembly, passed in 1869. The act declares 
that insane persons may be placed in a hospital for the insane by 
their legal guardians, or by their relatives or friends if they have 
no guardians ; but it also provides that the measure must be sane- 



5 

tioned by two physicians who shall certify under oath that the per- 
son is insane, and a fit subject for hospital treatment. The act does 
not require, but the hospitals do, for their own protection, that the 
application shall be made in writing by some person, either a mem- 
ber of the family, or some responsible friend. 

The question noAv before us is, whether upon a broad considera- 
tion of the various forms of insanitv, of our social habits, of the 
liability to mistake, of the sacredness of private grief, and the re- 
quirements of justice, anything more than this is necessary. The 
inquiry will take a two-fold direction, because we must consider 
not only the amount of abuse which any proposed restriction is in- 
tended to prevent, but also the amount of mischief which it may 
itself occasion, when not really required. If we dismiss all thought 
of the latter result, we shall have little hesitation in adopting any 
restriction for which some plausible reasons may be given. 

It is not denied that, for the most part, the medical certificate 
fulfils every requisite purpose. It is not denied that exceptional 
cases are, at the most, exceedingly few, and there seems, at first 
sight, a peculiar fitness in a measure which secures the performance 
of a painful duty without adding to the motives for delay, and 
shields the friends from all unnecessary exposure of domestic afflic- 
tion. It is in accordance with our national habits and customs, and 
especially with the right of persons — nowhere so extensively recog- 
nized as among us — to manage their own private affairs in their 
own way. But, it is alleged, the physician may be biassed by. his 
relations to the party or his family ; he may be deceived by false 
representations, or be honestly mistaken in his opinion. The 
friends, too, who make the application may, from fear or a worse 
motive, be too ready to confound caprice, or oddity, or passion, 
with insanity, and thus favor isolation when not strictly necessary. 
The liberty of any person in the community, it is said, is at the 
mercy of one or two doctors who may be induced by one motive 
or another, to sign a certificate of insanity. Such is not an uncom- 
mon style of argument, and it sometimes makes an impression 
even on men whose culture might be supposed to place them be- 
yond its reach. Hence, a prevalent idea that here is a frequent 
opportunity for flagrant abuses which should be met by stringent 
legislation. By some, it is proposed to make the isolation of the 
insane, in every case, the result of a legal procedure in the nature 



of an inquisition, to be conducted either by the municipal author- 
ities, or some magistrate, or a board of commissioners appointed 
for this purpose. Now, in regard to these two courses, it is not 
very obvious, at first blush, that either the possible abuses charged 
upon the former, or the advantages claimed for the latter, are so 
great as to set the question at rest. If there is to be an inquisition 
who so competent to make it as a physician ? If he has been ac- 
quainted with the person, as is very likely, he has materials for 
forming his opinion, which no one else may have. If, on the con- 
trary, he is a stranger, he is, of course, as far beyond the influence 
of prepossessions and biases as any functionary whom the law might 
designate for the purpose, while his decision would be attended 
with this advantage, that no unnecessary trouble or publicity is 
given to a domestic affliction, in the case of those of whose men- 
tal disease there can be no doubt whatever. To argue against the 
use of a thing from its possible abuse has always been regarded as 
very poor logic. It may be tliat the liberty of any person in the 
community is at the pliysician's mercy, and so is the life of every 
person who calls in a physician when he is ill ; but who hesitates to 
employ a physician from the fear that he may be bribed by wicked 
relatives to poison him ? In signing a certificate of insanity, a phy- 
sician performs a professional service in which he is amenable to 
his own sense of right and wrong and responsible to the laws of 
his country. Under what stronger obligations and sanctions can 
any one act ? 

Under stress of these objections to the medical certificate, it has 
been proposed to have the measure supervised and sanctioned by 
some executive or judicial officer of the state or county. In Scot- 
land, the sheriff is entrusted with this duty; and the Legislature of 
Massachusetts, last winter, provided that no one should be placed 
in a hospital for the insane without the knowledge and cojisent of 
a judge of a law court. It is not supposed that these functionaries 
are going into an exhaustive investigation of every case, because 
other duties would not permit it, so that it becomes a mere matter 
of form. 

Whatever course be adopted, no one thinks of dispensing with 
the medical certificate. But its value cannot long remain, unless 
physicians, in the performance of this professional duty are better 
protected than they now are. Indeed, leading physicians in this 



community, to avoid the peril of a suit at law, have concluded to 
sign no more certificates of insanity. 

Nothing evinces this distrust of any and all the known means 
resorted to for the purpose of preventing abuses, than the fact that 
in one State — Illinois — a trial by jury is provided for deciding the 
fact of insanity, in every case that offers for admission into a hos- 
pital for the insane. 

'iTo remove a person from his own home at the very moment when 
he seems most in need of the care and attentions of his friends, 
and place him in the hands of strangers, is always a painful duty, 
to be reluctantly and hesitatingly performed. The advice of phy- 
sicians, the remonstrances of friends, the failing strength of nurses 
and attendants, the increasing illness of the patient, are often dis- 
regarded, while the voice of affection pleads for a longer trial. To 
be obliged, under such circumstances, to call in a stranger to wit- 
ness the private grief, or, worse still, a band of strangers, as jurors, 
with a following of newspaper reporters, and hear those revelations 
of trouble and trial and sore calamity, which the coarsest sense of 
delicacy would keep within the bosom of the family, would serve 
as an additional excuse for delaying so disagreeable a measure. 
The sensitiveness on this point is so strong and so natural, that 
it is entitled to respect. The effect on the patient himself, pro- 
vided he is conscious of what is going on, and especially if, as is 
frequently the case, his mind is full of apprehensions and suspicion, 
is highly objectionable. Fresh excitement is furnished to that 
dread of impending evil, or bitter hostility, or some other morbid 
emotion, which may have possession of the mind, and thus bad im- 
pressions are made, not to be soon effaced. 

But, admitting these objections to the use of any other restriction 
than the medical certificate to be conclusive, still, it is contended, 
it is not improbable that persons may be held in confinement, who 
either never were insane, or are detained unnecessarily long after 
their recovery. Many firmly believe that in every hospital for the 
insane may be found persons who are simply victims of outrageous 
wrong, torn from their customary sources of enjoyment and subjec- 
ted to associations well calculated to craze the strongest intellect. 
To those who are practically acquainted with insanity, it is easy to 
see how an impression so utterly destitute of foundation has gained 
such currency in the world. With a large part of mankind, insanity 



tX 



implies noise, turbulence, confusion and incoherence of thought, 
folly and delusion. The more quiet and undemonstrative forms of 
the disease are utterly ignored, because not discernible to a super- 
ficial or unpracticed observation. The coolness, coherency and 
good sense which often mark the conversation of the insane, and 
the correctness of their conduct, are supposed to preclude the ex- 
istence of any mental disorder whatever. And even when some 
questionable traits are too prominent to be ignored, they are at- 
tributed to the common infirmities of our nature rather than to 
mental disease. The insane are not conscious of their insanity, and 
by ignoring altogether some facts, explaining some in a manner to 
suit themselves, and charging others with wrong-doing, they easily 
convince the incautious inquirer of their own mental soundness, as 
well as the dishonesty and malice of their friends. A story plau- 
sibly told is presumptively true ; and in the case before us, nobody 
troubles himself to hear the othei^de, unless it may be, probably, 
with a mind already made up. IConsidering the number of the 
insane who have been discharged from hospitals uncured, and of 
course with all their feelings of hostility towards those who have 
been instrumental in promoting their isolation unchanged, it is not 
strange that the impression in question should prevail extensively, 
Indeed, it would be more strange if it did not prevail. 

Again, it is alleged that in every hospital for the insane are 
many who, though technically insane, are not proper subjects for 
confinement, neither their own welfare nor the good of society re- 
quiring it, and that some outside party should pass upon the propri- 
ety of their detention. Here, too, we see the influence of those false 
notions respecting the nature of insanity, just mentioned. [A com- 
plete and correct account of such cases would show, with scarcely 
an exception, that, instead of being unjustly dealt with, they have 
been humanely placed where they enjoy as much of comfort, and 
suffer as little of discomfort, as their own mental condition will 
permit Some of them, for instance, may pass for patterns of pro- 
priety and injured innocence, suffering bitterly from the abuse of 
those to whom they had a right to look for kindness and protection, 
while, in fact,_ they were completely destroying the peace and com- 
fort of home by their jealousies and suspicions, their bursts of pas- 
sion, their irregular ways, their disregard of domestic proprietiea- 
their unhesitating mendacity, and even by scenes of violencej 



There is another class whose manifestations of disease are not very 
demonstrative,4or are^such as might pass for eccentricity or strong 
pecuharity.' They talk sensibly, behave correctly, and may make 
themselves somewhat useful. The stranger sees nothing of an ab- 
normal character, unless it may be a proclivity to exaggeration, an 
excessive self-confidence, and an indescribable hurry and restless- 
ness of movement. At home, they were careless of the little, per- 
haps the greater, proprieties of life, were up late at night, went out 
regardless of weather, and, though never violent or mischievous, 
were prone to get into trouble, and were a source of much anxiety 
to their friends. 

Persons belonging to one or another of these various classes 
easily enlist the sympathies of those whose acquaintance they hap- 
pen to make. They come to be regarded as victims of domestic 
cruelty, and the popular wrath is kindled by charges against faith- 
less husbands, or unfeeling wives, or heartless children. The ut- 
most rigors of legislation are invoked to deliver them from durance, 
and to punish those who^nder the guise of humanity, thus per- 
petrate a great wrong, fj^ow all these persons, probably, have 
proved by actual trial, prolonged perhaps for years, and repeated ^ 
again and again under different forms, to be very unfit inmates of ^ 
a private family, especially when made up, in part, of children and 
women of a nervous temperament.j To turn them adrift upon the 
world, where they find no welcome in those domestic circles whose 
peace and comfort they have persistently marred, and roam about i ...v 
from one boarding house to another, in a round of perpetual worri- 
ment, would be no kindness to them, but rather the severest kind 
of cruelty. If they have no home of their own, and no claim for 
one upon relations or acquaintances, where can they better find the 
protection and care which they need, than in a hospital for the 
insane ? J 

In the firm belief, however, that, after all, much wrong is ac- 
tually committed by depriving of their liberty persons who are but 
little if at all insane,many discreet and intelligent men are of the 
opinion that a supervising power should be lodged somewhere for 
the purpose of correcting mistakes, preventing abuses, and doino- 
justice generally in this matter of confinement. They would have 
a special permanent commission whose duty it should be to inves- 
tigate every case of doubtful insanity in the hospitals, or of alleged 



10 

unfitness for hospital treatment, and to discharge, or advise the dis- 
charge of, the patient, if they think proper. And in other respects, 
the interest of the insane might be confided to their oversight. 
The favorite remedy just now for all the ills of hospital confine- 
ment seems to be a roving commission, with plenary powers to 
visit all persons wherever confined on the ground of insanity, 
and discharge, or cause to be discharged, all such as they may deem 
not insane. 

The arrangement looks well and it is not strange that it should 
have found favor with some intelligent men. Considered, however, 
under the light of practical experience, and our knowledge of the 
ways and habits of men, it appears to be calculated to do immense 
harm, in the attempt to prevent an evil confessedly small. Such a 
commission would be led to its decisions by no fixed principles of 
law or science. Indeed, it is regarded, probably, as the principal 
merit of this provision, that it would be governed solely by an en- 
lightened sense of honesty, justice and fair dealing. This might be 
a merit were the questions to be decided such as could be readily 
understood and appreciated by ordinary men. But here are pro- 
fessional points to be considered, which, even with the best intentions, 
cannot be decided correctly without the knowledge of an expert. 
A disposition to do what is right is but a poor qualification for a scien- 
tific inquiry. It may even be a dangerous one. What cares a man 
for the scientific bearings of a question, who looks only at its moral 
aspects, and is sure that he cannot be misled by his own honest in- 
tentions ? In the class of cases where the interference of the com- 
mission would be most expected, there are always facts on the true 
significance of which the question of sanity or insanity must turn. 
If in any given case the conclusions of the commission coincide 
with those of the officers of the Hospital, the fact may inspire fresh 
confidence in the latter, and, to that extent, be of some service. But 
if, on the contrary, they differ, it is not easy to see why the decision 
of the commission, not one of whom may have had any practical 
acquaintance with insanity, can be more reliable than that of the 
officers whose field of observation may have embraced thousands 
of cases. How they are to proceed, by what course of inquiry 
they are to reach their object, is not very apparent. They visit a 
hospital containing three hundred patients, and make known to 
them their official character and the purpose of their visit. The 



It 

patients are invited to tell them their grievances, with the assur^nc^ 
that if any among them are not insane, they shall be discharged 
forthAvith. It is not overstating the matter to say that from fifty to 
a hundred would declare that they are wrongfully detained, and 
nothing in their conduct or conversatioji might belie the truth of 
their declarations. If they entertain delusions, no clue is furnished 
whereby they can be reached ; if they are disposed to mischief, no 
opportunity is afforded by the occasion to display the propensity ; 
no provocation leads them to relax the self-control which many of 
the insane possess in a remarkable degree. In this dilemma what 
is to be done ? The testimony of the officers and directors is exclu- 
ded by the conditions of the case, they being, it is supposed, inter- 
ested parties. The minutest inquiries of the patients themselves 
fail to bring out anything but the same uniform tale of wrong and 
outrage on the part of fathers or children, husbands or wives, 
guardians and relations, who, to conceal their own iniquities, take 
this means of consigning their victims to a sort of living death. 
There is obviously but one course left, if they would discharge their 
official duty so as to procure any satisfactory results. They must 
summon the friends and all who have been anyways connected with 
the patient, to appear and show cause why he should be confined ; 
and, in order to secure an impartial hearing of both sides, public 
notice should be given, inviting all who have any knowledge of the 
case, to attend the inquisition and give their testimony. The hear- 
ing of each particular case would occupy not less than two days. 
Supposing twenty-five per cent, of the three hundred cases in the 
hospital to claim an inquistion, which would be a low estimate, the 
commission would be employed in one hospital alone, one hundred 
and fifty days. At this rate, the hospitals in Pennsylvania, contain- 
ing about twenty- six hundred patients, would reqi^ire thirteen-hun^ 
dred days. True, the commission might be large enough to work 
by sub-committees, which would shorten the time, and, perhaps, 
diminish the expense ; for, of course, they must be paid, as well as 
the people who are summoned. And by the time they have gone 
the rounds of the hospital, the new comers, who have been stead- 
ily accumulating, will equally require their attention. If this simple 
statement of the proceedings carries with it an air of the ludicrous 
the fact does not proceed from any false coloring of the incidents 
themselves. They are given precisely as they must occur, if the 



12 

commissioners are determined to satisfy themselves by reliable evi- 
dence, whether any person is detained in the hospitals of this com- 
monwealth, who is not really insane. To hurry through a hospital 
once or twice a year, listen half an hour to a few of the large num- 
ber who claim their attention, and, on the strength of that conver- 
sation, decide to recommend the discharge or farther detention of 
the patient, — this would not be to meet the requirements of their 
office. A thorough judicial investigation, be it long or short, cheap 
or costly, in every doubtful or disputed case, is what the popular 
sentiment concerned in the matter, if it means anything beyond a 
windy sensation, implicitly demands. If this involves a practical 
absurdity, it ought to convince us that the present method is, with 
such a provision of law as I shall presently mention, under all cir- 
cumstances, best calculated to prevent abuses. The officers and 
trustees of our hospitals have no interest in retaining patients not 
insane. Whether kept or discharged, their compensation remains 
the same. In fact, however, in doubtful cases, their natural ten- 
dency is to discharge the patient, in order to avoid the odium and 
annoyance which they occasion. Nothing but a strong sense of 
duty, supported by the most satisfactory reasons, will induce them 
to retain a charge which brings them into the most unpleasant re- 
lations to others. 

Thus far I have gone on the supposition that there are actual 
abuses, however people may differ as to their extent. But the evi- 
dence in favor of the fact is far from reliable. The diseased im- 
pressions ot the patients themselves and the clamors of their self- 
constituted friends, are not evidence ; and yet upon these chiefly 
the current belief is founded. The observations of those who have 
had the most abundant opportunities to learn the real facts in the 
case, tell a very different story. /I have never met with a patient 
in any hospital for the insane, who, I had good reason to suppose 
finally, had never been insane, but had been committed, under pre- 
tence of insanity, in order to accomplish some iniquitous purpose ; 
and my observation embraces about three thousand persons mostly 
under my own charge^ I have been told by other gentlemen who 
have had charge of hospitals for the insane, that their experience 
has been much like mine. In two instances that came under my 
care, I had strong suspicions that there was no real insanity in the 
case. I thought that an irritability of temper caused by bodily disease 



13 

might have been provoked into violence by relatives who had some 
selfish purpose to serve by keeping the patient away from his home 
and customary pursuits. The sequel showed that my suspicions 
were groundless, and that the removal from home and the scenes 
and persons that were connected with unpleasant associations, only 
kept in abeyance for a time the manifestation of a disease which 
had been obvious enough at home and serious enough to require 
the restraint of a hospital. In England there has existed for more 
than forty years, a Board of Commissioners of Lunacy, as they are 
called, appointed by the crown for the purpose of visiting all the 
hospitals for the insane, public and private, with this very object in 
view among others, — of detecting the much alleged abuse of con- 
fining people who were never insane. I have been a diligent reader 
of their annual reports, in which their transactions are minutely 
described, and I have not found that they have advised the dis- 
charge of a single individual on this ground ; and, certainly, the 
manner in which their official duties have been discharged, has in- 
dicated no undue leniency towards the officers and directors of 
these institutions. The Earl of Shaftesbury, who was, for many 
years, a member of this commission, and who has been deeply in- 
terested in insanity and institutions for the insane, once declared 
in Parliament, that he had never known an instance of a sane per- 
son being held in confinement on the pretence of insanity. And 
this is in England, where, of all countries in the world, the abuse in 
question is supposed to be most frequent. This testimony would 
seem to be conclusive that it has no real existence, and that the 
safeguards already provided have been sufficient for the purpose. 
__ But, admitting all this, it is contended that, considering the 
public sensitiveness on this subject, it is necessary, in order to secure 
the popular confidence in the management of our hospitals, that 
there should be a supervisory power appointed by, and responsible 
directly to, the government. ( If, as has been already shown, such 
a power is entirely inefficient for any practical purpose, then it must 
be desired only as a sort of tub thrown out to amuse the whale. 
The tone of feeling in England, after a trial of more than forty 
years, shows conclusively that it would not even have this effect. 
There, although the commission has been watchful and suspicious 
to the last degree, the whale refuses to be amused. This must be 
apparent to any one much conversant with the newspapers, maga- 



14 

zines and books, of the day. It is notorious that anybody can 
obtain the ear of the pubhc, who can tell a tale of false imprison- 
ment, however improbable ; and, on evidence that would not be 
listened to in a court of justice, the newspaper-press is swift to 
pour out the vials of its wrath on the supposed offender. The 
horrors of the madhouse have become a favorite element in the plot 
of sensational novels. There is no reason to suppose that the result 
would be otherwise in this country. A sentiment like that in ques- 
tion cannot be affected by facts or arguments. The testimony o{ 
the wisest commission would avail nothing against the statements 
of a disordered mind still manifesting some degree of coherence and 
plausibility. We may as well, therefore, take things as they are — 
satisfied that the present safeguards are all that could be reasonably 
expected, and also that some popular distrust is one of the unavoid- 
able results of all correct hospital management. 

There is another view of the subject that ought not to be over- 
looked in considering the expediency of restrictive measures. All 
persons engaged in that speciality of the medical profession which 
is concerned with the treatment of insanity, tell us that the greatest 
difficulty they have to contend with is the reluctance of friends to 
bring the patient in the earliest stage, and the impatience which 
leads to a premature removal. Under the operation of these feel- 
ings, the number of recoveries is unquestionably lessened, and it 
cannot be doubted that they would be still farther lessened by the 
proposed restrictions. Their effect on the first mentioned feeling has 
been already alluded to, while their operation in England furnishes 
abundant testimony as to their effect in causing premature removals. 
During that period of the disease when the patient is coming to 
himself and, outwardly, seems free from all irrational thoughts and 
ways, great care is necessary, in order to conduct the process of 
restoration to a complete recovery, that he does not use his renewed 
powers too much or too soon — that he does not resume too soon 
the control of his own movements, nor mingle too soon in the 
scenes and associations of ordinary life. The patient himself, how- 
ever, may see no necessity for so much caution. He never felt 
better in his life, to use his own expression, and he sees no propri- 
ety in being detained any longer. In this impatient, fretful frame 
of mind, he pours his complaints into the ears of the commissioners, 
who, observing no manifestations of insanity, and unable to under- 



15 

stand the reasons which Influence the physician (because they are 
purely a matter of professional experience) are readily induced to 
advise his removal. 

The mischievous effects of the restrictive measures now used in 
England, are strikingly manifested in another class of cases, by no 
means a small one. The more active and obvious signs of disease 
have disappeared, the patient is quiet, orderly, and behaves like 
other people, and his remarks are shrewd and sensible, indicating 
neither delusion nor extravagance. But there is something in the 
air, manner, tone and way of the patient, imperceptible to the 
ordinary observer, but real enough to the expert, signifying that 
disease has not entirely vanished, but is only kept in abeyance — 
that freedom from restraint and the necessity of self-control, with 
opportunity to gratify a morbid impulse, would soon be followed by 
acts of mischief or violence. He knows, however, that his appre- 
hensions will not be appreciated by the Commissioners, and that a 
delay of the patient's discharge might, probably, be followed by an 
action for false imprisonment, ending in a verdict of heavy dam- 
ages. To obviate such a result he discharges his patient, with 
fearful forbodings that are too often realized. In England, some 
fifteen years since, a man was admitted into a private asylum, who 
had made, at least, two homicidal attempts. After a few month's 
stay, he was so far improved that no trace of disease was obvious 
on a casual inspection. His physician strongly suspected that the 
disease was only masked, not removed, but he feared to detain him 
longer, on grounds that could not be appreciated by ordinary ob- 
servers. So he discharged him, but his apprehensions were so 
keen, that he sent him home in charge of an attendant, with in- 
junctions to the family to exercise unceasing vigilance over his 
movements, but it was not long before he committed an atrocious 
homicide, without the slightest provocation. The case is a fair 
specimen of what may be expected where a physician in charge of 
an establishment for the insane is hampered in the exercise of his 
duty by Considerations that ought to have no influence whatever on 
his professional conduct. 

To meet this contingency of persons being kept in hospitals 
when no longer insane, the act of 1869 contained the following pro- 
vision : '' On a written statement, properly sworn to or affirmed, 
being addressed by some respectable person to any law judge, that 



t6 

a certain person then confined in a hospital for the insane is not in- 
sane, and is thus unjustly deprived of his liberty, the judge shall 
issue a writ of habeas corpus, commanding that the said alleged 
lunatic be brought before him for a public hearing, where the ques- 
tion of his or her alleged lunacy may be determined, and where 
the onus of proving the said alleged lunatic to be insane shall rest 
upon such persons as are restraining him or her of his or her 
liberty." The bill passed through its first stages with the same 
provision in this case as in that of persons committed to a hospital, 
viz., a commission composed of three members, and this was chosen 
in order to avoid the publicity, exposure, trouble and excitement inci- 
dent to a public trial in court, and the cause of incalculable mischief 
to the patient. It was thought, however, by some persons who had 
the power of giving their opinions the force of law, that the offence 
of keeping a person in confinement after his recovery should be 
dealt with in the swiftest, sharpest manner known to the law. And 
so, at the request of any one calling himself a respectable person, 
any judge in this city is obliged to transfer any victim of suffering 
from the rest and seclusion of an asylum to the repulsive scenes of 
the old Quarter Sessions court room, and deal with him as if he were 
a criminal on trial for his offence. To obtain anything like an 
adequate idea of this gross impropriety, we must put the case to 
ourselves, and conceive the subject of it to be a wife, or mother, or 
daughter or sister. 

The fallacy so prevalent in most communities, that insanity is 
always something superficial, and obvious to the casual observer, 
and never obscure and revealed by traits that are significant only 
to the expert, is singularly foolish, and as mischievous as it is foolish. 
Some idea of its prevalence may be obtained from the frequency 
with which it is intimated, in every grade of society, that the man 
who for many years has spent his days and nights surrounded by 
the insane, is less qualified to give an opinion as to the existence 
of insanity in a given case, than those whose knowledge of the 
disease is confined to a few general impressions respecting it. The 
abundance of his experience and the thoroughness of his studies 
are regarded as the very things that render his opinions unreliable, 
although, in accordance with all analogy, it might be supposed that 
they would enable him to see insanity where others, without such 
opportunities, cannot see it. A surgeon's large experience is not 



17 

supposed to render him all the more incapable of detecting a frac- 
ture or a dislocation which is unsuspected by other men. And he 
is no more able to give a reason for his belief, that would be any 
reason at all to others, than an expert in insanity sometimes is, for 
his belief that a certain person is insane. In fact, it is just the most 
dangerous cases in which the insanity is oftentimes the most ob- 
scure. Bellingham who killed Mr. Percival, McNaughton who 
killed the Secretary of Sir Robert Peel, and many others, manifested 
no insanity before the commission of their bloody deeds. They 
talked and acted and seemed very much like other men, and so, no 
doubt, they would have seemed to a board of commissioners in 
lunacy. And yet, I apprehend that an expert would have been 
satisfied, after a little observation, that the two just mentioned were 
unquestionably insane. To this notion, respecting the competence 
of experts in insanity, the legislature of Massachusetts, at its last 
sessions, gave a remarkable expression, by enacting that no super- 
intendent of a hospital for the insane should give a certificate of 
insanity. 

There is a class of insane for whose isolation a certificate of in- 
sanity alone is not sufficient. Persons become insane who have no 
family or friends, or, having family and friends, they are unwilling 
to authorize their confinement. The patient may still be at large, 
engaged, apparently, in his usual pursuits, etc., and with large social 
and business relations. For various reasons no one is willing to 
assume the responsibility of ordering his arrest and depriving him 
of his liberty. His wife or child fears to encounter his displeasure, 
his partner in business is deterred from interfering one way or the 
other, lest he may be suspected of sinister designs, and others, per- 
haps, are not aware of the urgency of the case. And even if one 
should feel willing to interfere, the patient's social or business rela- 
tions would seem to require some formal adjudication, in order to 
satisfy other parties of the necessity of a measure followed by such 
important consequences. It may lead to the dissolution of a busi- 
ness connection or the avoidance of a contract. It may enable him 
to escape a suit at law, or suspend execution of a judgment. The 
propriety of the measure is still more apparent when the presence 
of the disease is not perfectly obvious and the patient is likely, when 
the opportunity offers, to make use of every legal means in his 
power, to annoy and injure all who took any part in procuring his 



i8 

isolation. Under such circumstances it is peculiarly fit that the 
person should be committed by some process of law, whereby the 
family are spared the performance of a painful duty, and the public 
sentiment is satisfied. Accordingly, in the act of 1869, we have 
the following provision : 1 " Insane persons may be placed in a hos- 
pital by order of any court or law judge, after the following course 
of proceedings, viz.: On statement in writing of any respectable 
person, that a certain person is insane, and that the welfare of him- 
self or of others requires his restraint, it shall be the duty of the 
judge to appoint immediately a commission, who shall inquire into 
and report upon the facts of the case. This commission shall be 
composed of three persons, one of whom at least shall be a physi- 
cian and another a lawyer; in their inquisition they shall hear such 
evidence as may be offered touching the merits of the case, as well 
as the statements of the party complained of, or of his counsel; if 
in their opinion, it is a suitable case for confinement, the judge shall 
issue his warrant for such disposition of the insane person as will 
secure the object of the measure.'*! 

These then are the only requirements necessary to provide for 
the proper isolation of the insane, and if the law is honestly and 
dispassionately administered, we believe that the right of all par- 
ties will be secured. 



PRESS OF EDWARD STERN & CO., 
: 25 & 127 NORTH SEVENTH STREET, PHILA. 



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